Patient Name

• FOOD AND BEVERAGES

  • Nothing to eat or drink for 8 (eight) hours prior to dental procedure with the exception of water.
  • No fluids, including water, are to be consumed two (2) hours prior to dental procedure.
  I confirm.

• MEDICATIONS

  • It is essential to discuss with your dentist whether you should take medication(s) you otherwise take on a regular basis.
  • Under no circumstances should you continue the intake of medications unless otherwise discussed with your dentist prior to treatment, including but not limited to; marijuana, anti-depressants, psychotropic drugs, etc.
  I confirm.

• CLOTHING

  • Remove nail polish from at least one fingernail on each hand.
  • Wear loose casual clothing for your appointment (e.g., short sleeve t-shirt).
  • Female patients should wear loose/casual pants (no dresses or skirts).
  • All jewelry and valuables should be left at home.
  I confirm.

• SMOKING

  • Refrain from all forms of smoking prior to treatment (including marijuana and tobacco use).
  I confirm.

• TRANSPORTATION

  • Under no conditions can you drive yourself home.
  • A responsible adult with a vested interest in your safety must accompany you home.
  • Rides must check in with patients upon arrival (a taxi driver or similar service is not an acceptable escort).
  • Depending on the treatment you're having completed, your ride may be asked to collect your prescriptions while you are in your procedure.
  • It is recommended that someone stay with you for up to 6 (six) hours or longer if possible once you arrive home following your treatment.
  I confirm.

• CHANGE IN HEALTH STATUS

  • To cancel or change your appointment, 7 (seven) business days notice is required. If your appointment is cancelled within those 7 (seven) business days, your deposit will be held and an additional deposit will be required prior to rescheduling your appointment.
  • If your general health deteriorates (e.g. cold, cough, fever, etc.), please contact the program coordinator 3 (three) days prior to the day of the appointment.
  • If in doubt, please phone to report a change in your health status.
  I confirm.

• WOMEN ONLY - BREASTFEEDING

  • If you are breastfeeding it is imperative that you build up a 48-hour supply prior to your IV sedation appointment.
  • Following your appointment, you will be asked to waste any breast milk you produce for the next 48 hours.
  I confirm.

• FAILURE TO COMPLY

  • Taking your safety into consideration, should any of the sedation instructions fail to meet our standards, your treatment will be cancelled by the office and your deposit will be held. A new deposit of $300 00 will be required to reschedule your appointment. No exceptions will be made.
  I confirm.

If you have any questions, please do not hesitate to ask. It is important that you understand the circumstances surrounding this treatment.